2012_0525 (10)CIIECK ONE.
IRRIGATION DOMESTIC � FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS LD. #
LOCATION OF SERVICE: r , % /'� �. �* -r `'t � � i O
The bacicflow prevmtioa assembly detailed below has bem tested and maintained as requited by TNRCC
regulations and is certified to be operating within acceptable parameters_
TYPE OF ASSEMBLY
C Reduced Pressure Principle ,gs'S Pressure Vacutmm Breaker
� Double Check Valve o Atmosphere Vacuum Breaker
MaaufacttzTer
Model Number
Serial Number
.` ;
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BRF'AT�'R
Double Check Valve Assembly
1st Check
tad Cbecl:
-;
Size ;( ° "i
Located At �'r +� _� �_ � .�
The above is certified to be true.
Firm Name � , • . - � Cerrtified Tester
Film Address Cert_ Tester No. ? Date
Gauge #
Data last accuracy tested _ ___ _ _ -
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BRF'AT�'R
Double Check Valve Assembly
1st Check
tad Cbecl:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Tiehi o
Closed Tight d
Leaked o
Opened at
Dsid
Opined at
osid
- osid
RP- arid
��� p
Did not Opm o
Leaked '�
Repairs
and
Materials
Used
Test Atirr
Repair
DC- Closed
Tight a
Closed Tight v
Opined at
acid
Opined at
osid
acid
RP rid
The above is certified to be true.
Firm Name � , • . - � Cerrtified Tester
Film Address Cert_ Tester No. ? Date
Gauge #
Data last accuracy tested _ ___ _ _ -
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy